Parent Enrollement Form - Marvin Thomas

Student Information

Student First Name

Student Last Name

Date of Birth

Age

Today's Date

School Name

Homeroom Teacher

Preferred Pronouns (optional)

How did you hear about Marvelous Girls?

Why You Want to Join

What made you want to join? (Check all that apply)

I want to make new friends I want to become a better leader I want to build confidence My parent or guardian suggested it A teacher or counselor recommended it I like after-school programs and activities I want to talk about things that are important to me

Other reason for joining (if any)

What are you hoping to learn or work on during the program?

What do you enjoy doing in your free time? (hobbies, sports, music, art, etc.)

How You Feel About Yourself Today

I feel confident in who I am.

I speak up when I have something to say.

I make good choices when things get hard.

I feel good about my schoolwork.

I get along well with other students.

I know how to handle it when I'm upset or frustrated.

I believe I can be a leader.

I feel comfortable asking for help when I need it.

I have at least one adult I can trust and talk to.

I feel excited about my future.

In Your Own Words

Name one thing you're proud of about yourself.

Name one thing you'd like to get better at.

Who is someone you look up to, and why?

What does the word "leader" mean to you?

Is there anything else you want the Marvelous Girls team to know about you?

Parent / Guardian Information

Parent/Guardian Name

Relationship to Student

Primary Phone

Alternate Phone

Parent Email

Preferred Contact Method

Home Address

City, State, ZIP

Emergency Contact

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Emergency Contact Alternate Phone

Pickup Authorization

Authorized Pickup – Name & Relationship #1

Authorized Pickup – Name & Relationship #2

Authorized Pickup – Name & Relationship #3

Health & Support Information

Does your student have any allergies (food, environmental, medication)?

Yes No

If yes, describe allergies (include severity and required medication)

Does your student take any medications during 3:00–6:00 PM?

Yes No

If yes, describe medications

Does your student have an IEP, 504 Plan, or learning accommodations?

Yes No

If yes, describe what would help us support her best

Anything else that would help our facilitators support your student?

Your Goals for Your Student

What are you hoping your student gains from Marvelous Girls?

5.6 Consent & Acknowledgements

I give permission for my student to participate in Marvelous Girls.

I understand that sessions are held Tuesdays and Thursdays from 3:45 P

I understand that sessions are held Tuesdays and Thursdays from 3:45 PM to 5:15 PM for 5 weeks (10 sessions total).

I agree to arrange pickup by the end of each session, or authorize one

I agree to arrange pickup by the end of each session, or authorize one of the adults listed above.

I give permission for program staff to seek appropriate medical care i

I give permission for program staff to seek appropriate medical care in case of emergency.

I understand that program fees, if applicable, are my responsibility (

I understand that program fees, if applicable, are my responsibility (Parent-Paid) or covered by the school (School-Funded).

I have provided accurate health and emergency information to the best

I have provided accurate health and emergency information to the best of my knowledge.

Optional: I give permission for my student to be photographed or filme

Optional: I give permission for my student to be photographed or filmed for program documentation and marketing purposes.

Parent/Guardian Printed Name (acts as signature)

Date Signed

Enroll Your Student in Marvelous Girls.

Student Information

Why You Want to Join

How You Feel About Yourself Today

In Your Own Words

Parent / Guardian Information

Emergency Contact

Pickup Authorization

Health & Support Information

Your Goals for Your Student

5.6 Consent & Acknowledgements

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